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Table of Contents    
Year : 2018  |  Volume : 66  |  Issue : 5  |  Page : 1526-1528

Does ‘one size fit all' in academic neurosurgery?

Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, India

Date of Web Publication17-Sep-2018

Correspondence Address:
Dr. George C Vilanilam
Department of Neurosurgery, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum - 69 5011, Kerala
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0028-3886.241366

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How to cite this article:
Rajasekar G, Vilanilam GC. Does ‘one size fit all' in academic neurosurgery?. Neurol India 2018;66:1526-8

How to cite this URL:
Rajasekar G, Vilanilam GC. Does ‘one size fit all' in academic neurosurgery?. Neurol India [serial online] 2018 [cited 2019 Feb 16];66:1526-8. Available from:

“The worst form of inequality is to try to make unequal things equal “


We were greatly inspired by Professor Rajshekhar's exhortations to develop a culture of academic neurosurgery,[1] effectively balanced with surgical expertise, basic research and soft skills. The crux of the message of the article was that, by widening his/her circle of service to include research and teaching, a neurosurgeon could contribute further beyond the 6000-15000 patients that he/she would operate upon in a lifetime. The concepts elucidated are very appealing but we wonder if a universal definition of ‘academic neurosurgery' and ‘circle of service' could apply to all nations and neurosurgeons, in a world of glaring inequalities and asymmetry?

  Asymmetries and Imbalances Top

Gross disparities exist in global access and availability of healthcare.[2],[3],[4] It is estimated that 60% of the world's neurosurgeons serve 14% of the world's population [Table 1].[2] It is saddening to note that about 11 countries in the world have no neurosurgeons at all. Providing safe, timely and affordable neurosurgical care in resource-poor nations is a daunting challenge. Equity of neurosurgical services and care all over the world can only be a utopian dream.[5],[6]
Table 1: Per Capita neurosurgical human resources[6],[7],[8],[9],[10],[11]

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India, having about 1950 neurosurgeons serving a population of 1.3 billion people, is much better off in the neurosurgical inequality debate.[7],[8],[9],[10],[11] The calculation further leads to a figure of 1 neurosurgeon for about 6.5 lakh people in India, much lesser than the world average of 1 neurosurgeon for 2.3 lakh people. Globally, 22.6 million people require neurosurgical consultations and 13.8 million require neurosurgical operations every year.[6] Extrapolating these figures to India, it is estimated that 3.9 million people require a neurosurgical consultation and 2.3 million require neurosurgical operations every year in India. Thus, assuming a balanced workload and an ideal access of patients to neurosurgical services, a neurosurgeon in India would need to perform about 1179 neurosurgical operations every year to meet this demand.

In India, a neurosurgeon would normally be employed in any of the following scenarios,[7]

  1. Academic government institutions (with or without neurosurgical training programs)
  2. Private universities (with or without neurosurgical training programs)
  3. Private hospital practices (single or multiple hospital based) with or without neurosurgical training programs, as a part of the Diplomate of the National Board (DNB) training program.

Irrespective of the type of neurosurgical practice, the responsibilities of a neurosurgeon include:

  1. Patient care: Outpatient, inpatient, emergency consultations, surgical operations and post- operative care
  2. Training: Mentoring and teaching neurosurgical trainees in surgical operations, diagnostic skills and guiding research work
  3. Research: Basic and clinical research and its scientific publication output
  4. Miscellaneous: Neurosurgical advocacy, community initiatives, administration, etc.

The distribution of an individual neurosurgeon's time to each of the above responsibilities varies according to the individual, institutional and social priorities. It is a common stereotyped thought that most neurosurgeons in academic institutions are involved in research and those in private practice are busy with surgical work. This is a misconception as significant research contributions are often made by private practitioner neurosurgeons, while many of those in academic institutions are busy with routine surgical chores, having hardly any research contributions.


Hence, the surgical operative work may take its toll on research aspirations, more so in developing countries with a limited neurosurgical work force.[12] When day-to-day surgical chores are pitted against research pursuits, the former takes priority. It becomes essential to pay heed to the suffering patient beckoning for our help, while research aspirations could wait. Thus, maintaining a perfect surgeon-scientist balance becomes a tough task, though we all aspire to achieve it. To widen the circle of service to science and society, the contemporary neurosurgeon is expected to be a surgeon-scientist, delicately balancing surgical work and clinical research but that ideal situation may be difficult to realise.


The impact of scientific research extends across future generations and undoubtedly widens the researcher's sphere of influence, as was well illustrated by Professor Rajshekhar's words.[1] Resecting a meningioma may make an impact on one person's life, while researching safer means to do it, could help millions. Besides the scientific contribution, the fact that the research output is measurable in terms of various bibliometric measures (citations, research gate scores etc.) that add to the scholarship matrix of the authors and is extremely useful during departmental promotions, also remains undisputed.[12] A surgeon's operative work and clinical contributions are often intangible in terms of academic measurable scores. These clinical achievements cannot be convincingly put forth as a measure of scholarship and academic achievement to an accrediting authority or academic promotion board. Hence, they need to be bolstered and supported by measurable bibliometric achievements. Therefore, to measure up, surgeons perhaps need to be given time off from surgical work to perform pure, unadulterated and undistracted research pursuits, if institutional priorities and the surgical workload may permit. This is almost impossible to achieve this utopian goal in countries with scarce neurosurgeons.

Beyond research

Soft skills, which are also part of the list to widen the circle of service in neurosurgical practice, are often intangible, abstract and some of them cannot be taught in a typical neurosurgical residency program.[1] While presentation skills and bedside manners could be taught, others like empathy and presence of mind can only be imbibed while on the job in the cauldron of a long neurosurgical career.[1],[12]

In resource poor nations, the key challenges in widening the circle of neurosurgical service may further include,[1],[2],[5],[6]

  1. Developing low cost economically viable indigenous solutions to neurosurgical needs, e.g., surgical innovations (Warf's choroid plexus cauterisation and endoscopic third ventriculostomy in resource poor Africa, locally developed shunt systems, drill, etc.)
  2. Mentoring local champions, including surgeons and allied workers, for meeting the rural neurosurgical demands and discouraging a purely urban centric neurosurgical practice. e.g., Dr. Dilan Ellegala,[8] trained in the United States, taught para-medical personnel in resource poor Tanzania, to perform many lifesaving bedside neurosurgical interventions
  3. Neurosurgical advocacy, community based epidemiological research and preventive initiatives, e.g., helmet regulations, safe pregnancy initiatives, etc.

We are grateful to Professor Rajshekhar for shaking us from the reveries of a mundane neurosurgical life and passionately inspiring us to widen our circle of service and sphere of responsibility. We, however, make a humble plea to tailor the yardstick for measuring an academic neurosurgeon's circle of service based on his/her nation's neurosurgical needs and resources. Would it be fair for a neurosurgeon from Tanzania to be weighed on the same measuring scale of ‘academic neurosurgery’, as his/her peer from Japan ?

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Rajshekhar V. Widening the circle of service: The gift of academic neurosurgery. Neurol India 2018;66:637.  Back to cited text no. 1
[PUBMED]  [Full text]  
Warf BC. Educate one to save a few. Educate a few to save many. World Neurosurg 2013;79:S15-e15.  Back to cited text no. 2
Punchak M, Mukhopadhyay S, Sachdev S, Hung YC, Peeters S, Rattani A, et al. Neurosurgical care: Availability and access in low-income and middle-income countries. World Neurosurg 2018;112:e240-54.  Back to cited text no. 3
Park KB, Johnson WD, Dempsey RJ. Global neurosurgery: The unmet need. World Neurosurg 2016;88:32-5.  Back to cited text no. 4
Dempsey RJ. Neurosurgery in the developing world: Specialty service and global health. World Neurosurg 2018;112:325-7.  Back to cited text no. 5
Dewan MC, Rattani A, Fieggen G, Arraez MA, Servadei F, Boop FA, et al. Global neurosurgery: The current capacity and deficit in the provision of essential neurosurgical care. Executive Summary of the Global Neurosurgery Initiative at the Program in Global Surgery and Social Change. J Neurosurg 2018; 27:1-10.  Back to cited text no. 6
Vilanilam GC, Easwer HV, Menon GR, Karmarkar V. “Magister neurochirurgiae": A 3-year crash course' or a 5-year ‘punctilious pedagogy'? Neurol India 2017;65:434-7.  Back to cited text no. 7
Ellegala DB, Simpson L, Mayegga E, Nuwas E, Samo H, Naman N, et al. Neurosurgical capacity building in the developing world through focused training: Clinical article. J Neurosurg 2014;121:1526-32.  Back to cited text no. 8
Feng L. Neurosurgery in the People's Republic of China: An update. International Neuroscience Journal 2015;1:12-15.  Back to cited text no. 9
Kobayashi S, Teramoto A. The current state of neurosurgery in Japan. Neurosurgery. 2002;51:864-70.  Back to cited text no. 10
Rosman J, Slane S, Dery B, Vogelbaum MA, Cohen-Gadol AA, Couldwell WT. Is there a shortage of neurosurgeons in the United States? Neurosurgery 2013;73:354-66.  Back to cited text no. 11
Vilanilam GC, Sudhir BJ, Kumar KK, Abraham MA, Nair SN. Are Indian neuroscience clinicians perishing without publishing? Neurol India 2015;63:807-8.  Back to cited text no. 12


  [Table 1]


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